|
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
|
Facility
OP
|
$2,263.56
|
|
|
Service Code
|
CPT 43239
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,057.78 |
| Max. Negotiated Rate |
$2,263.56 |
| Rate for Payer: Wellmark IA HMO |
$2,057.78
|
| Rate for Payer: Wellmark IA PPO |
$2,263.56
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)
|
Facility
OP
|
$2,263.56
|
|
|
Service Code
|
CPT 43247
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,057.78 |
| Max. Negotiated Rate |
$2,263.56 |
| Rate for Payer: Wellmark IA HMO |
$2,057.78
|
| Rate for Payer: Wellmark IA PPO |
$2,263.56
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
|
Facility
OP
|
$2,263.56
|
|
|
Service Code
|
CPT 43251
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,057.78 |
| Max. Negotiated Rate |
$2,263.56 |
| Rate for Payer: Wellmark IA HMO |
$2,057.78
|
| Rate for Payer: Wellmark IA PPO |
$2,263.56
|
|
|
Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)
|
Facility
OP
|
$2,263.56
|
|
|
Service Code
|
CPT 43249
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$2,057.78 |
| Max. Negotiated Rate |
$2,263.56 |
| Rate for Payer: Wellmark IA HMO |
$2,057.78
|
| Rate for Payer: Wellmark IA PPO |
$2,263.56
|
|
|
ESSURE TUBAL OCCLUSION
|
Facility
IP
|
$1,577.00
|
|
| Hospital Charge Code |
8025903
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,103.90 |
| Max. Negotiated Rate |
$1,419.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,419.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,419.30
|
| Rate for Payer: Cash Price |
$1,261.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,182.75
|
| Rate for Payer: Medical Associates Commercial |
$1,182.75
|
| Rate for Payer: Midlands Choice Commercial |
$1,103.90
|
| Rate for Payer: United Healthcare Commercial |
$1,419.30
|
|
|
ESSURE TUBAL OCCLUSION
|
Facility
OP
|
$1,577.00
|
|
| Hospital Charge Code |
8025903
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$788.18 |
| Max. Negotiated Rate |
$1,419.30 |
| Rate for Payer: Aetna of IA Commercial |
$1,419.30
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,419.30
|
| Rate for Payer: Aetna of IA Medicare |
$898.89
|
| Rate for Payer: Amerigroup Medicaid |
$795.91
|
| Rate for Payer: Amerigroup Medicare |
$796.38
|
| Rate for Payer: Cash Price |
$1,261.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,182.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$788.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$788.18
|
| Rate for Payer: Medical Associates Commercial |
$1,182.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$788.50
|
| Rate for Payer: Midlands Choice Commercial |
$1,103.90
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$800.33
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,182.75
|
| Rate for Payer: United Healthcare Commercial |
$1,419.30
|
| Rate for Payer: United Healthcare Managed Medicare |
$930.43
|
|
|
ESTABLISHED PATIENT NURSE ONLY CHARGE
|
Professional
|
$30.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
8068920
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna of IA Medicare |
$8.14
|
| Rate for Payer: Amerigroup Medicaid |
$8.42
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$9.77
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8.30
|
| Rate for Payer: Medical Associates Commercial |
$15.47
|
| Rate for Payer: Medical Associates Managed Medicare |
$8.14
|
| Rate for Payer: Midlands Choice Commercial |
$21.00
|
| Rate for Payer: Partners Health Alliance Commercial |
$12.21
|
| Rate for Payer: Wellmark IA HMO |
$12.50
|
| Rate for Payer: Wellmark IA PPO |
$12.50
|
|
|
ESTAB PATIENT DETAILED
|
Professional
|
$357.00
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
8101317
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$89.78 |
| Max. Negotiated Rate |
$249.90 |
| Rate for Payer: Aetna of IA Medicare |
$89.78
|
| Rate for Payer: Amerigroup Medicaid |
$92.83
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$107.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$91.58
|
| Rate for Payer: Medical Associates Commercial |
$170.58
|
| Rate for Payer: Medical Associates Managed Medicare |
$89.78
|
| Rate for Payer: Midlands Choice Commercial |
$249.90
|
| Rate for Payer: Partners Health Alliance Commercial |
$134.67
|
| Rate for Payer: United Healthcare Commercial |
$107.37
|
| Rate for Payer: Wellmark IA HMO |
$137.00
|
| Rate for Payer: Wellmark IA PPO |
$137.00
|
|
|
ESTAB PATIENT EXPANDED
|
Professional
|
$244.00
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
8101316
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$60.81 |
| Max. Negotiated Rate |
$170.80 |
| Rate for Payer: Aetna of IA Medicare |
$60.81
|
| Rate for Payer: Amerigroup Medicaid |
$62.88
|
| Rate for Payer: Cash Price |
$195.20
|
| Rate for Payer: Cash Price |
$195.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$72.97
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$62.03
|
| Rate for Payer: Medical Associates Commercial |
$115.54
|
| Rate for Payer: Medical Associates Managed Medicare |
$60.81
|
| Rate for Payer: Midlands Choice Commercial |
$170.80
|
| Rate for Payer: Partners Health Alliance Commercial |
$91.22
|
| Rate for Payer: United Healthcare Commercial |
$66.26
|
| Rate for Payer: Wellmark IA HMO |
$93.00
|
| Rate for Payer: Wellmark IA PPO |
$93.00
|
|
|
ESTAB PATIENT FOCUSED
|
Professional
|
$148.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
8101315
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$32.49 |
| Max. Negotiated Rate |
$103.60 |
| Rate for Payer: Aetna of IA Medicare |
$32.49
|
| Rate for Payer: Amerigroup Medicaid |
$33.59
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$38.99
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$33.14
|
| Rate for Payer: Medical Associates Commercial |
$61.73
|
| Rate for Payer: Medical Associates Managed Medicare |
$32.49
|
| Rate for Payer: Midlands Choice Commercial |
$103.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$48.74
|
| Rate for Payer: United Healthcare Commercial |
$49.69
|
| Rate for Payer: Wellmark IA HMO |
$50.00
|
| Rate for Payer: Wellmark IA PPO |
$50.00
|
|
|
estradiol 1 mg Tab
|
Facility
IP
|
$1.49
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of IA Commercial |
$1.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.34
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: United Healthcare Commercial |
$1.34
|
|
|
estradiol 1 mg Tab
|
Facility
OP
|
$1.49
|
|
|
Service Code
|
CPT A9270
|
| Hospital Charge Code |
43705982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of IA Commercial |
$1.34
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.34
|
| Rate for Payer: Aetna of IA Medicare |
$0.85
|
| Rate for Payer: Amerigroup Medicaid |
$0.75
|
| Rate for Payer: Amerigroup Medicare |
$0.75
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.74
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.75
|
| Rate for Payer: Midlands Choice Commercial |
$1.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.34
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.88
|
|
|
Estradiol Level DMCL
|
Facility
OP
|
$190.00
|
|
|
Service Code
|
CPT 82670
|
| Hospital Charge Code |
8037841
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna of IA Commercial |
$171.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$171.00
|
| Rate for Payer: Aetna of IA Medicare |
$108.30
|
| Rate for Payer: Amerigroup Medicaid |
$95.89
|
| Rate for Payer: Amerigroup Medicare |
$95.95
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$142.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$95.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$94.96
|
| Rate for Payer: Medical Associates Commercial |
$142.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$95.00
|
| Rate for Payer: Midlands Choice Commercial |
$133.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$96.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$142.50
|
| Rate for Payer: United Healthcare Commercial |
$171.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$112.10
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
Estradiol Level DMCL
|
Facility
IP
|
$190.00
|
|
|
Service Code
|
CPT 82670
|
| Hospital Charge Code |
8037841
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$133.00 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna of IA Commercial |
$171.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$171.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$142.50
|
| Rate for Payer: Medical Associates Commercial |
$142.50
|
| Rate for Payer: Midlands Choice Commercial |
$133.00
|
| Rate for Payer: United Healthcare Commercial |
$171.00
|
|
|
ESTRIOL UNCONJUGATED
|
Facility
IP
|
$146.00
|
|
|
Service Code
|
CPT 82677
|
| Hospital Charge Code |
8037490
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
|
|
ESTRIOL UNCONJUGATED
|
Facility
OP
|
$146.00
|
|
|
Service Code
|
CPT 82677
|
| Hospital Charge Code |
8037490
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna of IA Commercial |
$131.40
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$131.40
|
| Rate for Payer: Aetna of IA Medicare |
$83.22
|
| Rate for Payer: Amerigroup Medicaid |
$73.69
|
| Rate for Payer: Amerigroup Medicare |
$73.73
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Cash Price |
$116.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$109.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$73.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$72.97
|
| Rate for Payer: Medical Associates Commercial |
$109.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$73.00
|
| Rate for Payer: Midlands Choice Commercial |
$102.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$74.10
|
| Rate for Payer: Partners Health Alliance Commercial |
$109.50
|
| Rate for Payer: United Healthcare Commercial |
$131.40
|
| Rate for Payer: United Healthcare Managed Medicare |
$86.14
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
Estrogens Fractionated (E1 and E2) DMCL
|
Facility
IP
|
$190.00
|
|
|
Service Code
|
CPT 82671
|
| Hospital Charge Code |
8037842
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$133.00 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna of IA Commercial |
$171.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$171.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$142.50
|
| Rate for Payer: Medical Associates Commercial |
$142.50
|
| Rate for Payer: Midlands Choice Commercial |
$133.00
|
| Rate for Payer: United Healthcare Commercial |
$171.00
|
|
|
Estrogens Fractionated (E1 and E2) DMCL
|
Facility
OP
|
$190.00
|
|
|
Service Code
|
CPT 82671
|
| Hospital Charge Code |
8037842
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna of IA Commercial |
$171.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$171.00
|
| Rate for Payer: Aetna of IA Medicare |
$108.30
|
| Rate for Payer: Amerigroup Medicaid |
$95.89
|
| Rate for Payer: Amerigroup Medicare |
$95.95
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$142.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$95.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$94.96
|
| Rate for Payer: Medical Associates Commercial |
$142.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$95.00
|
| Rate for Payer: Midlands Choice Commercial |
$133.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$96.42
|
| Rate for Payer: Partners Health Alliance Commercial |
$142.50
|
| Rate for Payer: United Healthcare Commercial |
$171.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$112.10
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
ETHICON ENDO GIA GUN
|
Facility
OP
|
$480.00
|
|
| Hospital Charge Code |
8026300
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$239.90 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna of IA Commercial |
$432.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$432.00
|
| Rate for Payer: Aetna of IA Medicare |
$273.60
|
| Rate for Payer: Amerigroup Medicaid |
$242.26
|
| Rate for Payer: Amerigroup Medicare |
$242.40
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$360.00
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$240.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$239.90
|
| Rate for Payer: Medical Associates Commercial |
$360.00
|
| Rate for Payer: Medical Associates Managed Medicare |
$240.00
|
| Rate for Payer: Midlands Choice Commercial |
$336.00
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$243.60
|
| Rate for Payer: Partners Health Alliance Commercial |
$360.00
|
| Rate for Payer: United Healthcare Commercial |
$432.00
|
| Rate for Payer: United Healthcare Managed Medicare |
$283.20
|
|
|
ETHICON ENDO GIA GUN
|
Facility
IP
|
$480.00
|
|
| Hospital Charge Code |
8026300
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna of IA Commercial |
$432.00
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$432.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$360.00
|
| Rate for Payer: Medical Associates Commercial |
$360.00
|
| Rate for Payer: Midlands Choice Commercial |
$336.00
|
| Rate for Payer: United Healthcare Commercial |
$432.00
|
|
|
etomidate 2 mg/mL IV 10 ml SDV
|
Facility
IP
|
$28.02
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.61 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Aetna of IA Commercial |
$25.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.22
|
| Rate for Payer: Cash Price |
$22.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.02
|
| Rate for Payer: Medical Associates Commercial |
$21.02
|
| Rate for Payer: Midlands Choice Commercial |
$19.61
|
| Rate for Payer: United Healthcare Commercial |
$25.22
|
|
|
etomidate 2 mg/mL IV 10 ml SDV
|
Facility
OP
|
$28.02
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
43700347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Aetna of IA Commercial |
$25.22
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$25.22
|
| Rate for Payer: Aetna of IA Medicare |
$15.97
|
| Rate for Payer: Amerigroup Medicaid |
$14.14
|
| Rate for Payer: Amerigroup Medicare |
$14.15
|
| Rate for Payer: Cash Price |
$22.42
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$21.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$14.01
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14.00
|
| Rate for Payer: Medical Associates Commercial |
$21.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$14.01
|
| Rate for Payer: Midlands Choice Commercial |
$19.61
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$21.02
|
| Rate for Payer: United Healthcare Commercial |
$25.22
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.53
|
|
|
etonogestrel 68 mg Imp
|
Facility
OP
|
$2,063.12
|
|
|
Service Code
|
CPT J7307
|
| Hospital Charge Code |
43700461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,031.15 |
| Max. Negotiated Rate |
$1,856.81 |
| Rate for Payer: Aetna of IA Commercial |
$1,856.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,856.81
|
| Rate for Payer: Aetna of IA Medicare |
$1,175.98
|
| Rate for Payer: Amerigroup Medicaid |
$1,041.26
|
| Rate for Payer: Amerigroup Medicare |
$1,041.88
|
| Rate for Payer: Cash Price |
$1,650.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,547.34
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1,031.56
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1,031.15
|
| Rate for Payer: Medical Associates Commercial |
$1,547.34
|
| Rate for Payer: Medical Associates Managed Medicare |
$1,031.56
|
| Rate for Payer: Midlands Choice Commercial |
$1,444.18
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$1,047.03
|
| Rate for Payer: Partners Health Alliance Commercial |
$1,547.34
|
| Rate for Payer: United Healthcare Commercial |
$1,856.81
|
| Rate for Payer: United Healthcare Managed Medicare |
$1,217.24
|
|
|
etonogestrel 68 mg Imp
|
Facility
IP
|
$2,063.12
|
|
|
Service Code
|
CPT J7307
|
| Hospital Charge Code |
43700461
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,444.18 |
| Max. Negotiated Rate |
$1,856.81 |
| Rate for Payer: Aetna of IA Commercial |
$1,856.81
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1,856.81
|
| Rate for Payer: Cash Price |
$1,650.50
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1,547.34
|
| Rate for Payer: Medical Associates Commercial |
$1,547.34
|
| Rate for Payer: Midlands Choice Commercial |
$1,444.18
|
| Rate for Payer: United Healthcare Commercial |
$1,856.81
|
|
|
etoposide 20 mg/mL 5ml MDV
|
Facility
OP
|
$84.68
|
|
|
Service Code
|
CPT J9181
|
| Hospital Charge Code |
43700495
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.32 |
| Max. Negotiated Rate |
$76.21 |
| Rate for Payer: Aetna of IA Commercial |
$76.21
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$76.21
|
| Rate for Payer: Aetna of IA Medicare |
$48.27
|
| Rate for Payer: Amerigroup Medicaid |
$42.74
|
| Rate for Payer: Amerigroup Medicare |
$42.76
|
| Rate for Payer: Cash Price |
$67.74
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$63.51
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$42.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$42.32
|
| Rate for Payer: Medical Associates Commercial |
$63.51
|
| Rate for Payer: Medical Associates Managed Medicare |
$42.34
|
| Rate for Payer: Midlands Choice Commercial |
$59.28
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$42.98
|
| Rate for Payer: Partners Health Alliance Commercial |
$63.51
|
| Rate for Payer: United Healthcare Commercial |
$76.21
|
| Rate for Payer: United Healthcare Managed Medicare |
$49.96
|
|
